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In their letter, colleagues Jacob et al. raised further evidence of
the lack of standardised safety netting. We thank them for their comments
emphasizing the disparity between paediatric trainees' perception of their
safety netting practice and their documentation in the medical notes.

To overcome the lack of information on the difference of given safety
netting advice and its documentation...

In their letter, colleagues Jacob et al. raised further evidence of
the lack of standardised safety netting. We thank them for their comments
emphasizing the disparity between paediatric trainees' perception of their
safety netting practice and their documentation in the medical notes.

To overcome the lack of information on the difference of given safety
netting advice and its documentation in the medical notes, the authors
propose the introduction of a checklist. However, at this moment the
effective components or the best way to perform this safety netting
management still remains unknown.

A systematic review of Neill et al. states that incomplete
information on the illness of their child leaves parents still in need for
help.(1) Moreover, irrelevant information reduces parents' trust in the
intervention.(1) We know that parental knowledge and satisfaction improved
more after video discharge instructions than after written discharge
instructions alone.(2) So to proceed we think the next step is to focus on
the parental role in the decision making process. One could think of
parental monitoring of alarming signs and symptoms of their febrile child.
A study on self-referred children with fever emphasized that many parents
properly judged and acted on their febrile child's severity of illness.(3)
In England every parent is trained to recognise petechial rash,(4) we
might enlarge this knowledge to other alarming or reassuring signs and
symptoms. This could be initiated for example for respiratory rate, a
useful marker of pneumonia, one of the most frequent serious illness at
the ED.(5) We are aware of current projects on this topic. A next step is
evaluating the impact of such strategies providing improved information on
patient (re)consultation.

In addition to the recognition of deterioration, an important gap in
safety netting literature is its time frame strategy. The development of
optimal safety netting management should include clinical signs and
symptoms, but also a disease specific time frame to inform parents when
they should seek help again. This combination of safety netting
determinants may establish new starting points for improvement of care.

Safety netting in the Emergency Department (ED) is key to the
practice of safe medicine. Following the article by de Vos-Kerkhof (1),
we present further evidence to suggest that there is a lack of
standardised safety netting. In addition, we found a disparity between
paediatric trainees' perception of their safety netting practice and what
they actually documented in the medical notes.

Safety netting in the Emergency Department (ED) is key to the
practice of safe medicine. Following the article by de Vos-Kerkhof (1),
we present further evidence to suggest that there is a lack of
standardised safety netting. In addition, we found a disparity between
paediatric trainees' perception of their safety netting practice and what
they actually documented in the medical notes.

In a retrospective case notes review of 100 consecutive ED
attendances to our hospital seen by the paediatric team and discharged
from ED, only 16% had documentation that the families had been told about
the existence of uncertainty around the diagnosis and the course of the
illness. This compares unfavourably with the fact that 73% of surveyed
paediatric trainees reported that they routinely mentioned this to
families. Furthermore, the signs and symptoms to look for had only been
documented in 27% of cases, though 88% of trainees reported discussing
this with the family. 39% of the notes reviewed had no specific safety
netting documentation of any kind.

It is clear that for non-consultant paediatricians, who are the
clinicians seeing most referred children in ED, a gap exists between the
safety netting that they report undertaking and what is documented. This
may be in part because they provided verbal safety netting advice without
documenting it but it also suggests that safety netting procedures are
poor, despite the clinical and medico-legal imperative for adequate safety
netting and documentation advocated by the National Institute for Health
and Care Excellence(2).

Clearly training for junior doctors on safety netting and its
documentation needs to improve. A safety netting checklist and more high
quality patient information leaflets may help clinicians to offer adequate
advice and information to families at the time of discharge.
(297 words)